Another On Line Experience

I have previously written in the EdX programs and had expressed concerns. Specifically my major concern was that one found problems that could have been mediated by internal directions or by not over relying on external sources. The first problem was lack of discovering how to enter an equation and the second having to download and rely upon third party software, and thus not focusing on the course but some software package which one may not ever use.

I have just complete a Coursera course on of all things Equine Nutrition. Why, well frankly it was a mistake but I thought why not. Well I just finished it today and frankly it was quite useful. Unlike EdX it was simple, a five week course, and despite the Scottish accent of the Instructor it was interesting and enlightening. I actually learned something beside how Coursera works. Yes I passed and did reasonably well, so I found it rather useful. Much simpler than the MIT course, but somewhat akin.

Is there a future here? I now have several benchmarks, EdX, Coursera, and my Harvard Medical CME courses. The CME courses are lectureless, you just had better know or relearn the materials, but they are focused and intense. The Coursera are apparently for a wider intro audience and are just fine.

It will be interesting to see how these evolve but my thanks to the Coursera folks, a fine job well done!

New Insight on Rawls

The book on John Rawls by Thomas Pogge is valuable contribution to the ever increasing body of professional literature regarding this late Harvard Professor and proclaimer of what Justice is. The book is overall a superbly written and presented addition to what is available. It is an excellent interpretation of Rawls’ works and has parts of the discussion which present some semblance of balance with other thinkers; here I argue the discussions on Nozick and Sandel, both also of Harvard, are very worthy additions in the discussion. Rawls writings opened up a new dialog for political scientists in the late 20^th century by espousing a humanist and communitarian approach to Justice, where Justice meant the sharing of a society’s wealth, and inherently assuming that what any individual achieved was done so in the context of the contributions of all those around them.

Let me first begin by providing a summary of the Rawlsian theory. The essence of Rawls’ approach to “Justice” is predicated on three elements;[1]

Original Proposition: There exists a means and method for a society to establish a Contract amongst and between them. This Contract thus created in this society of the just is one that maximizes the return on every transaction to the least of the individuals in the society.[2]This approach to contractarianism is one related to individuals in a non-bargaining environment establishing between and amongst them a “contract” to govern their society.[3] There are two elements contained herein.

The first is the essence of a contract, and in fact a form of social contract between the members of society and amongst them as a whole. This is a restatement of the classic contractarian view of a society.

The second element is that of a view towards man as a constrained and unconstrained view of human nature. [4]

The unconstrained view states that man, individually and in concert, has the capabilities of feeling other people’s needs as more important than his own, and therefore we all act impartially, even when the individuals own interest are at stake.

The constrained view is to make the best of the possibilities which exist within the constraint.

For example, the constrained view of universal service is one which would state that if it costs a certain amount to provide the service, an there is a portion of the society not able to purchase the service, then there is no overriding need to provide it if such a provision is uneconomical and places a significant burden on the other member of society. The unconstrained view, as a form of socialism, states that if there is the least of us in want then they should have access to it at whatever cost.[5] Rawls approach to this contract is one wherein the individuals in the society collect themselves as individuals, and agree to a plan for the operations of that society, and they accomplish behind some veil of anonymity. That is no one has the benefit of knowing who may be getting more or less, including themselves.

First Principle of Justice: each person shall have equal rights and access to the greatest set of equal fundamental personal liberties.

Second Principle of Justice: social and economic inequalities are to be arranged so that they both, (i) provide the greatest benefit to the least advantaged. and (ii) attached to positions available to each individual under conditions of fair equality of opportunity.

This latter element of the Rawlsian world is often viewed as a Schupeterian form of socialistic control. If we were to define the public welfare by a function as some measure W, and each individual listed as a variable I, then the policy choice, which we would call P, is chosen such that the welfare is maximized for the least advantaged. What this states is that we want to maximize the society welfare subject to the constraint that no individual suffers due to the change or execution of a policy P.

We can compare this to the utilitarian school which states that we seek the maximization of the average welfare for all of society, sort of a raising of all the boats approach which is not constrained on what happens to any one individual, but to society as a whole. This approach is the basis of the Ramsey tax policy. The Ramsey approach is Rawlsian whereas the approach of an Adam Smith or other utilitarians is the average approach.[6]

Now let me address several of the specific sections of the book. This is in no way inclusive; it merely highlights some of the worthwhile parts of the book.

pp 11-15. The involvement of Rawls in WW II is a major turning point in his life. He fought in the battle of Leyte in the Army as an enlisted man, albeit a college graduate. His decision, frankly a wise one to not obtain a commission, since if he had he could and most likely would have been drawn into Korea, did place him in places of significant carnage. I had written a book on Navy actions during Leyte, my father was there, and the brutal land as well sea engagements left lasting change on all the men involved. Although the author does reflect this it clearly is of interest to have explored this seminal event on the part of Rawls and better understand how this set the path for his future views of human existence and the relationships he would suggest imposed on society. In my experience interviewing dozens of men who fought there the effect was lasting and world view changing. Although presented, it truly deserves deeper understanding.

p 20. The author presents some of the conflicts during the 60s which further made for his world view, especially the perceived draft inequity. For example, for Rawls, he could not understand education deferments, that is, those, say studying engineering, being deferred while those, not in college, being drafted. In essence this was a utilitarian approach, in that it was assumed that the draft scheme benefitted society on average better than equality in the draft. To Rawls, the very poorest student or person should have equal treatment. One sees a kernel of his theory of Justice emerging.

p 28. The author starts with the statement: “Justice is the first virtue of social institutions.” My concern here is several-fold. First, it is declaratory without a basis. Second, fails to define Justice, virtue, and social, and I will assume I understand the term institutions. This is a Rawls statement, the beginning of his work. The second part of the sentence missing is “as truth is of systems of thought.” Yes Rawls uses this in almost a Marxian declarative manner, or like Rousseau, man and his chains, but it leave one wondering what this justice thing really is. The author does begin defining it and his use of social justice for Rawlsian Justice is telling. For social justice had already had a long history in Progressive movements for almost a century by the time the book was published. Again one wonders how much of this also influenced Rawls.

p 29. The author discusses somewhat the origin of the Theory of Justice. One would like, as I have stated before, to have seen a more expansive overview, one linking a bit more of past social justice thought. I did find his analysis on this page reminiscent of Scholastic thinking and methodology.

p 30. There is a discussion of happiness. One is left asking what happiness is. This of course is a problem with many who approach this area, use of terms like happiness, fairness, all too often are in the eye of the beholder and have long histories of use by different people for different purposes. However the author will return to this important issue later.

pp 43-44. This is an excellent introductory approach to Rawls. The author clearly discusses the concepts of (i) consequentialism, (ii) humanism, and (iii) normative individualism, all elements of the Rawlsian theory.

pp 48-48. The discussion on the anonymity issue, the veil of ignorance, is reasonably well done. My only difficulty was the detailed discussion was less than fully descriptive.

pp 53-54. Here the author does go into some detail on Rawls own objections to happiness. This I found quite enlightening and exceptionally well done. The two objections to using happiness are clear and to the point and definitely worth spending some time on.

pp 67-67. This is the maximum versus average argument, it is my argument from Mill and the Utilitarians to Rawls and the Redistributionists. Rawls wants to consider the least of us in his use of Justice, Mill just wants to make sure on average we are all just fine. Mill and the Utilitarians have a more “democratic” metric, namely the group on average, and Rawls want to make certain that we do not disenfranchise anyone.

p 75. The author has an interesting discussion regarding the allocation of goods, redistribution and society. It is a critique of certain elements of Rawls but clearly worth examining.

pp 178-185. The author compares Rawls to some of his critics. He considers two at length, Nozick and Sandel. The Nozick opposition is characterized by three objections: (i) that Rawls is a redistributionist, and this violates fundamental property rights, (ii) that Rawls in his redistributionist view demands a sharing on equal basis denying individual contributory differences, and (iii) the Rawlsian view of collectivism, namely that any single individual benefits from the contributions of all in society and thus no individual stands alone, only on the efforts of all others in society. In essence Rawls is an anti-individualist, and Nozick is a libertarian. This is not exactly at total odds, but it is fairly close.

pp 185-188. Here the author does a comparison with Sandel and his communitarian views. Although, not at as great a set of odds as with Nozick, the author does a superb job in making these contrasts.

Overall the author provides a professional, articulate, accurate and highly readable and accessible overview and analysis of Rawls. As I have indicated the deeper analysis and understanding of Rawls the man would be exceedingly useful. For example, what led him to evolve these ideas, what resonances helped him along the way, why did he believe that he was right and others were in error? Understanding Rawls as a philosopher I believe requires understanding Rawls as a man. I have yet to fully see that task achieved. Yet this book is a very valuable contribution to that effort.

---

[1]See Kukathas and Pettit, Rawls, Stanford Press, 1990, for an excellent expository of the Rawlsian theory.

[2]Indeed in the Rawlsian world the individual posits their position and does so without any negotiation and thus posits a position assuming that that individual will be the least amongst players in that society. Such a position, to create justice in that society, is a maxi-min position.

[3]This is the same in many ways of the Social Contract envisioned by Rousseau.

[4]See Sowell, Conflict of Visions, Basic, 2002, pp. 18-24. Sowell does present an interesting a simple analysis of several of the issues.

[5]See Schumpeter, Capitalism, Socialism, and Democracy, Harper, 1942, pp. 167-186. Specifically, he defines socialism as; “an institutional pattern in which the control over the means of production and over production itself is vested in a central authority- or, as we may say, in which, as a matter of principle, the economic affairs of society belong to the public and not the private sector.”

[6] This is the Baumol Willig theorem in economics which uses the first Rawlsian approach to maximizing the return subject to a single constraint; namely that the monopolist suffers no harm. This is of course a different twice to Schumpeterian socialism, wherein a monopolist usurps the power of the state for its own benefit.

Office or no Office, What Shall It Be?

The Yahoo CEOs demand to return to the Office strikes a chord. I have mixed feelings on offices, having spent about half my career in one and the other half away from one. Large Corporations waste so much time at meetings that one wonders how any work is accomplished. I recall as I moved up the NYNEX/Verizon hierarchy how I spent more than three fourths my time at such meetings as Quality, Ethics, "Planning". and the like that I could never see how work got done, and in fact it did not. It was the Phone Company.

As the  NY Times recounts:

A memo explaining the policy change, from the company’s human resources department, says face-to-face interaction among employees fosters a more collaborative culture — a hallmark of Google’s approach to its business. 

In trying to get back on track, Yahoo is taking on one of the country’s biggest workplace issues: whether the ability to work from home, and other flexible arrangements, leads to greater productivity or inhibits innovation and collaboration.

In my experience the answer is a bit of yes and no. First of all Yahoo seems in my opinion to be a dying entity, just is no one seems to have told the patient. But that aside, it is nice to have key people accessible, but that can be accomplished in various ways. But again leadership is essential, if you demand certain performance from your troops you must be out in front doing ten times more. If you do not lead by example then people immediately see you as a self centered egoist. Not a good thing when you are trying to right a sinking ship.

The other side of this argument is that if you want people in the Office then when they are away from the Office the corollary is that you leave them alone; no cell phone calls, no emails, no video conferences, no instant messages, no nothing. Yet I suppose that this side of the equation will not be honored.

Productivity can be quite high "at home" or not in the Office. I can be ten time more productive. Yet my group productivity demands face to face contact, not even a video conference makes it. So I travel to Boston, Washington, etc to "meet" people since effective collaboration is contact intensive. Thus one must separate the two functions; collaboration versus concentration. Programmers, writers, etc may function better alone and at "home". Executives must meet, but then again they are on the road frequently.

Bottom Line: It all depends and no one size fits all. But again one leads by example. I spent a portion of my life doing "turn arounds" and that demands up front leadership, leadership that has people follow, not be ordered to do so.

The Idea Factory: A Review

It is frequently said that history is written by the victors. This is a history written by the defeated. It is a hagiography of a select few who were at Bell Laboratories (Also Bell Telephone Laboratories, BTL). It also is a paean for the return of structures like Bell Labs despite the overwhelming evidence of the technical and economic success of the entrepreneurial and “creative destruction” mode which has been a dominant driver of our economy since the breakup of AT&T, and even slightly before.

This is a review of The Idea Factory by Gertner. It is placed here rather than on Amazon due to the negative attacks.

Let me commence this review with some bona fides. From 1964 through 1972 I spent a considerable amount of time back and forth from MIT and Bell Labs. I worked in Electronic Switching and in the Defense side; I worked at West Street, just before it closed, then Holmdel, then Indian Hill and finally Whippany. I saw many sides of the business as an MTS during that period. Then again from 1986 through 1990 I became Head of R&D at NYNEX, now Verizon, and thus had to manage parts of Bellcore, the residue of some of Bell Labs. In between I have run CATV companies, Satellite companies, fiber companies, wireless companies, here in the US and in over 20 other countries. I have written over 125 papers and fourteen books, many relating to telecom. Thus my approach to this book brings the “distinct disadvantage of experience”, unlike the author, who appears to have none in this space.

Now as to the many principals in this book I have known some personally. John Pierce taught a semester seminar at MIT, I believe the spring of 1971 when I was finishing my degrees, and I was strongly advised to go. I did and it was an hour of hubris each and every time. At that time the world was already changing, I had worked on Apollo and was essential to its guidance system; I had even worked my first start up the end of 1969, albeit as a consultant yet I saw the future. Pierce was stuck in the past, and the longer he spoke the more I saw that. Big monopoly R&D was still his mantra while we were seeing small startups in the back yard buildings around MIT, companies like DEC. I would see Shannon, a ghost like person, in Building 26 from time to time. He was a total contrast to Wiener, who wandered around with his cigar, listening and speaking to whoever would listen. I never heard Shannon utter a word, and I was teaching Information Theory at the time.

I believe that there is a story in Bell Labs, but that this book grossly fails to tell it. The story is one of a monopoly controlled entity whose actions actually set our technology back, perhaps a decade. Add this to the NASA boom in the 1960s and you had a perfect storm which diverted American entrepreneurialism back for a lost decade, thus it led to the Japanese bubble in the 1980s, but by 1990 the US caught fire again. That is a story worth examining.

Page by Page Comments

The following are some page by page comments and then I will provide some overall observations.

p. 3 The author starts by contemplating how ideas begin. He uses wireless communications and computer networks, and he then uses these two areas as exemplars of what Bell Labs produced that our present and future depend. Unfortunately that is not really how it worked. Let me begin with computer networking. That began with ARPA, first Larry Roberts and then Bob Kahn. Add Vint Cerf, Irwin Jacobs, Kleinrock, and yes even yours truly, I did the satellite connections, and we have the beginning of a new world. But what of BTL? As told to me by one of the principals at ARPA, they went to Murray Hill to seek support to use a Bell modem to test out the ARPA net. A couple of folks from ARPA enter a room filled with BTL executives. Before they could talk about their needs, the BTL Execs told them that if they wanted anything then just give BL an open ended contract, they will decide what is needed, develop it, operate it, and they, ARPA may then determine whatever they want with the data. Fortunately ARPA folks did not comply, the thanked their guests, and went out and assembled a team that in a highly entrepreneurial manner developed the Internet. An Internet that did away with AT&T. It was hubris that led to their ultimate collapse. It was the hubris of the monopoly, of the very structure that the author praises, never asking to see the other side.

p. 5 The author denigrates the entrepreneur by lauding the colossus of BTL. The very nature of technology development is the continual “creative destruction” that is required, the change of the past with the replacement of the new. The typical example is when BTL developed and implemented the Electronic Switching System, ESS No 1, it was a computer controlling massive amounts of mechanical switches, fereeds. Fred Kappel was the CEO of AT&T at the time and he wanted to see this progress to a fully electronic system. Fred tried to get the Labs to develop such a system but the rigidity of the Labs management said that he would get it in due time. So Fred went to Canada. You see ATT owned a large interest in Bell Canada, and they owned Bell Northern Research. He then asked them on the sly to develop an all-digital switch. They did, the first one was sold to New York Telephone and from that came the competitor to Western Electric, Northern Telecom. It was my way or the highway at BTL, even to ATT. Yet one person at ATT said no, and sought a “creative destructive” manner to solve th problem.

p 81 The statement that “it would become a kind of received wisdom that many of the revolutionary technologies …” One must ask by whom was this wisdom received. There were other voices, many other voices. In fact in the 60s there was an explosion of other voices, in many ways driven by the Cold War demands for innovative technologies. Places like MIT Lincoln Labs, developing technology well beyond what Bell Was doing. Silicon Valley was just starting, large Defense contractors were seen many offshoot startups, like Linkabit, STI, and others which were pushing telecom well beyond limits at BTL. Satellite companies like COMSAT had developed TDMA technology, and even developed spread spectrum for use in enhanced telephony, key to all mobile systems today. ARPA was doing packet radio. There was an explosion of technology, much from outside BTL. In contrast when one of my Czech partners, the former Communist head of the Czech PTT, Moscow educated, told me they use Bell System Technical Journal designs to try to reverse engineer systems until they found out Erickson was much farther ahead!

p. 118 The author again and again brings out the mid-west origin of many of the people. This stylistic approach of using the same facts over and over can and does become a distraction.

pp 122-123 Again we have a mid-west hero. But this time it is BTLs adventures in radar. In reality there was a battle between MIT, BTL, and MIT won with the Rad Lab. However BTL learned a lesson and tried to be certain this would not happen again. At the bottom of p 123 the author alludes to Shannon and his work on fire control systems. In reality there were many independent contributors to the enhanced fire control in WW II< and one of course was Norbert Wiener and his use of random processes with control theory. Wiener was a true mathematician, Shannon was at best an applied mathematician. Wiener’s problem was he all too often made certain the answer was acceptable to the best of the best, Shannon gave simple and highly readable descriptions available to the many.

p. 128-129 The classic Shannon papers were so successful not only because of the insight but more importantly because of the presentation and simplicity of paradigms. Before his peers one had complex pure mathematics or hand waving engineering. What Shannon did brilliantly was two things. The block diagram in the book and the one missing, the binary symmetric channel, BSC. From the BSC came innumerable advance in information theory and communications. But Shannon also took the reader through the problem as if it were a simple novel, it was not a challenge until you got to the end. It clearly was one of the most brilliantly written papers ever, beyond its ideas. It made the reader comfortable, you could sit down and become engaged.

p. 130-131 The problem with many non-technical authors is how best to explain Shannon’s results. Simply they were threefold; first, any signal can be defined in terms of some measure call information. Second, knowing the information at a source, then one can also determine the information transferring capacity of a channel, the stuff between source and sink, and this delimits the rate at which you can transfer the information. Third, this is often overlooked, the source coding theorem, which states that you can compress the stuff that you send. The author did not discuss this.

p. 153-154 The author discusses Kelly College and the Techs. Kelly College was a way to educate the people inside. However one thing I could never find was how a Number 1 Crossbar worked. I could do that when speaking with craft folks but not at Kelly College. I did get queuing theory, but from a BTL perspective, namely looking at trunks and overload trunks. Kelly College turned into a Master’s Degree program first at local Universities and then at major Institutions. We had a large group at MIT. Now for Techs, they were good, they had been trained typically in the military and could advance to AMTS, Associate Members of the Technical Staff. But there was a glass ceiling. If you got your degrees after starting at BTL you were almost always never going to become MTS. I always found that disturbing.

pp 184-185 The author’s reference to the Organization Man is quite on point. BTL was a hierarchical system, it made the Catholic Church look like an interloper. Everyone knew their position and if you had a godfather you could make it, otherwise you became a “40 year man” In addition you had no ability to move about unless they asked you to do it. The entrepreneur was anathema. You were told what to do and you did it their way. Kelly clearly was a top down manager. The tale the author tells of his public termination of supervisors after WW II, apparently lauded by the author, is one of the most demeaning and demoralizing acts I have ever seen. You just do not do that, it is not gentlemanly.

p 191 Pierce is introduced with the accent on his being an only child. That characteristic is brought out several more times. It would have been useful to have explored some of these issues: poor families, only child, mid-west, and on and on. In my observations a strong New Yorker would most likely not fit well.

pp 216-219 This is a long discussion regarding Pierce and the satellite. It appears that Pierce was enamored with the technology and not the system, service, and economics. As I will show later he decided on a design to provide excellent voice quality, albeit economically infeasible.

p. 225 This is classic Pierce and accepted by the author as gospel. The author states:

“He (Pierce) doubted satellite engineering could advance at the same rate without Bell Labs …”

That was in reference to the establishment of COMSAT, even though ATT owned some 25-40% of the new entity. The author fails to seek the veracity of such a statement. For by this time NASA existed and NRL and other Government entities have extensive satellite experience. In fact the experience well exceeded anything within BTL. This approach by the author again and again accepting statement at face value is a true and basic failing of the book.

p. 250 The author by this point is becoming annoyingly repetitive. We have heard multiple versions of Shannon stories or Shockley tales.

p 252 The development of the integrated circuits was a massive loss for BTL. It was done by entrepreneurs outside the Bell System. The author’s comment by Ross that “it could never be reliable” is again a reiteration of the not invented here syndrome. But by the time this happened the very foundations of BTL were crumbling. DoD was demanding more advanced systems, technology, and the industry and more importantly the people, were finding new ways to deliver this in a more efficient and cost effective manner. Not the Labs way.

pp 302-303 The discussion about the Drucker paths is worth some note. The alternative of going into business for itself and making money from its patents what in reality is what companies like Qualcomm actually did in the very same time period. When at NYNEX I was the instigator in our venture fund investment in Qualcomm, for after all Irwin Jacobs had been my faculty advisor at MIT.

Specific Observations

Let me make a few detailed observations using the words of people who were there. I choose two, Jack Harrington who was my boss at COMSAT and Paul Rosen who was my boss at MIT Lincoln Labs. I find their observations regarding Bell Labs on point and reflective of some of the serious issues the author failed to consider.

Let me begin by looking at Pierce and his satellite program. He had the big balloon, a jump the shark act, to put BTL out in front. It was good PR but poor technology. Out of that came COMSAT, I was there for six years, and that became the focus for satellite and other communications technologies. COMSAT was set up by law in 1962 and was incorporated with an IPO in early 1963. But they raised some $500 million in anticipation of having to build the satellite system proposed and designed by Pierce and the BTL team. Yet that was a low orbit system requiring tracking antennas and dozens of satellites with many launches to keep them up there. It was the most expensive design ever considered. In 1961 Pierce had written a detailed article in Scientific American detailing his design. He concluded:

The cost of a global satellite communication system will be large-on the order of $500 million-but no larger than the cost of undersea cables that could provide the same geographical coverage. (One cannot say the "same service," because undersea cables do not yet provide the band width needed for television.) Assuming that the experiments of the next few years are encouraging, there should be no lack of capital, domestic and foreign, to share the cost of a world-wide satellite communication system.

Pierce’s proposal was:

A system of 40 satellites in polar orbits and 15 in equatorial orbits would provide service 99.9 per cent of the time between any two points on earth. A.T.&T. has proposed that the system contain about 25 ground stations so placed as to provide global coverage. Bell Telephone Laboratories is building an experimental satellite to test the feasibility of such a system; NASA has agreed to launch it early next year for a fee of about $6 million, to be paid by A.T.&T.

The technical problems were tremendous, many of which I suspect Pierce had no clue about. But just after COMSAT raises the necessary $500 million Harold Rosen and his Hughes team launch Syncoms 1 and 2, synchronous satellites (February and July 1063). Much less expensive and much more effective. They just need simple antennas and they only require 3 for global coverage.

From oral histories at COMSAT Jack Harrington, a former MIT Professor but head of Engineering at COMSAT when I got there states[1]:

NGS: Although just the fact that you knew that you could in fact launch the satellite, put it into geosynchronous orbit, didn't necessarily mean that it would be a commercially viable system because of the time delay.

JH: Yeah, there were time delay effects which under certain circumstances can be troublesome. The Bell people [Bell Telephone Laboratories ] made a big issue of that.

NGS: The "Bell people" meaning John Pierce?

JH: Yeah . The Bell Labs people in general and the AT&T people in general. I wouldn't particularize it, but John Pierce was certainly one of the strong spokesmen of the time delay effects on satellite communications.

NGS: Now, do you feel that there was pressure on the part of the engineering staff by the people at AT&T? Obviously, who had TELSTAR, had had success with TELSTAR.

JH: I think it was clear that if one left it up to the Bell System to specify the nature of the satellite system, the specification would have gone to a medium-altitude satellite, and the reason was to control the delay. Which is annoying, no question. It's very annoying.

Pierce it appears designed the satellite system to meet delay issues and not cost. This was a pandemic issue at Bell. Cost and any tradeoff were thrown out the window if the “best” in their sole opinion could be delivered.

Now to the issue of computer networking. In an oral history with Paul Rosen, one of the MIT Rad Lab team, he states[2]:

At the time Bell Labs had great men working on this, and they said if one drives a telephone line over 600 bits per second, one has arrived at the end of the flat earth, and you've had it. With my simple device I did 1800 bits per second consistently. That was a big deal, because they were going to install thousands of miles of transmission. They (the Bell Labs people) adopted my modem – initially. Jack Harrington and I got a patent on it. I did the grunt work and Jack did the analysis post facto that it would work. One of my colleagues said, "Oh, you're going to get rich on this." We had an incompetent attorney at MIT. You have been with academics. I think you may know that some the administrative people associated with academic institutions believe that they have tenure until ten years after they die. This attorney was terrible. The problem was that he let me write a patent application that was much too constrained.

Much, much broader claims. The result was that when this system ultimately went into the field indeed my design was the one that Western Electric (under Bell Labs aegis) built for its early stuff. There was an Air Force contracts officer who thought that Harrington and I should have gotten something out of it. We got point-triple-O nothing because no one would buy the patent and it belonged to the government. The government gave it to Western Electric and that was the end of it. In the meantime, having worked at these sites first on the components that made up these machines, and second on these machines and third on installing them at sites we began to make a system. I became the leader of the group that built and installed these pieces of equipment at the various sites.

Now what is most startling about this is that Rosen did this in 1945! BTL was still only providing 300bps modems as late as 1980. It was this very 300 bps modem that the ARPA folks wanted to upgrade gratis and that they already knew could and had been done. Where BTL had competent patent attorneys Rosen is quite clear as how MIT just lost a tremendous opportunity. Yet it would be again in the early 1970s when ARPA folks, many from MIT, went to BTL again, they in their normal arrogant manner dismissed them, and the ARPA folks took their demand to people like Linkabit, Codex and others, and thus we had a Hayes modem of the early 80s, and now we have modems of 10s of Gbps on silicon chips. Creative destruction at work, and a missed opportunity for the author to have grasped an important observation and made it worthwhile.

Overall Observations

Let me now make some overall observations than that I have delineated some of my concerns as well as having provided a background of facts which counter the overall theme.

The Message is a Hagiography: This is one continual praise after another for a small portion of what was BTL. There were at times upwards of 15,000 people at the Labs and many just worked away in the tombs of technology. They were buried in routine and endless tasks and creativity was often stifled. I am reminded of an office mate of mine for a shot while at Whippany. I suspect he was mid to late 40s and had  PhD in mechanical engineering. For twenty plus years he had been with the underwater cable group, an area praised by the author. He would come in at 9 promptly each day, open his door, then go down get coffee, read the Wall Street Journal, call his broker, then do some work, then go to lunch at 11:30, then go off to a Bell Labs club of some sort till 1:30, return with another cup of coffee, do some work, the call his broker, then read the Journal again, then leave at 5 PM on the dot! He did this every day! It was like a prison sentence, nothing new, and nothing different. For he was the stress-strain expert on the underwater cable and thus he was good for the next twenty years, he was what we called a “forty year man”. He was the guy who had done X and X had a 40 year life in the Bell System so he was stuck with it forever. I saw hundreds of grey 40 year men! They do not come out in this book.

The Style is Overly Repetitive: As I have noted above the author tells the same tale a dozen different times and a dozen different ways. He tells and retells Kelly, Shannon etc.

It is a Paean to Pierce: One must ask why so much on Pierce. His claim to fame was an analysis of the Travelling Wave Tube, a microwave amplifier. Nice job but sooner or later some PhD student would have done the same thing. Pierce was abrasive, arrogant, and frequently in my opinion wrong. One needs look no further than the satellite tale. Shannon was elusive, Pierce arrogant, and Kelly abusive. Nice group of folks to hang around with.

It Fails to Tell the Other Side: The Rad Lab at MIT made seminal developments in radar and communications. The Labs, according to many writers, always was trying to shut them down and take over the work. One needs look no farther than Norbert Wiener and his feedback systems for fire control. The Labs had invited Wiener solely to pick his brains and then to do an end around run. Fortunately Wiener was smart enough. The other side would be to tell what MIT Rad Lab had done. One needs look no further than the classic Rad Lab Series of books, each of which must have started a dozen new companies over time. I use the Servomechanism Rad Lab book to design Apollo guidance systems, and Antennas for designing satellite systems. There were no such products from Bell. Take Shockley’s book on semiconductors. I tried it a few times but there were much better documents from those outside of BTL.

BTL Was Set Up to Preserve the Monopoly: The Kingsbury Decision made ATT a legal and untouched monopoly. In fact it was written into the Antitrust laws and thus it could do fairly whatever it wanted to and the Labs was a means to preserve that bulwark against any intruder. Their portfolio of patents was a protective measure, less a technological platform to deliver the best available. It was a bulwark against competitors and innovation. The author never seems to be even aware of these issues. Somehow he gives the impression that they actions were purely and always benevolent.

What of the Other People: To understand BTL and to opine on it being the proper paradigm for research one must look at it in its entirety. Not as a single set of a few “strange” people, albeit creative. What of the thousands of “40 year men” who when the Labs went bust were thrown into a world they could not understand. The outside have moved centuries forward and these rejects were cast asunder.

BTL Publications: There were two BTL publications; The BSTJ and Bell System Journal on Economics. The BSTJ seemed to serve two purposes: an in house technology release organ and a vehicle for publishing interesting technical desiderata. The Economics journal was different, it was the house organ attempting to gain peer acceptance in economics addressing issue which were related to justifying ATT positions with regulators. The economics justified the ATT filings but the people were at Bell Labs. One would have liked the author to explore these publications, what they did, how influential they were, and what the staff thought of them.

The General Executive Instructions, GEI: There was a manual, in fact a book shelf of them, called the GEI. It told you what size office you would have the desk type, the chair, the phone, travel restrictions, vacations,  the tiles on the floor, the promotion and salary scales, the organizations structure. It was all regimented to a fine point, and it applied to all. It surpassed anything one could think of even in the Federal Government. It was suggested that this was Kelly and his heavy hand but I was not there long enough to truly understand. But it was pervasive, and no entrepreneurial company could ever exist under such binding regulations.

Thus in my opinion the author had a wonderful opportunity but totally missed it. In my opinion, true historical writing requires both sides, the writer must be competent to understand when they are being used and by whom. Was Bell Labs a sine qua non of R&D. Not really. It did insure the monopoly control over telecom for decades but it also became the seed of its very destruction. Today there is not a single US manufacturer of telephone switching equipment. So this is a legacy?

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[1] http://www.comara.org/legacy/oralhistory/

[2] http://www.ieeeghn.org/wiki/index.php/Oral-History:Paul_Rosen

Take the Children Away!

I have been reading the proposals for pre-K Federally mandated education. As the White House States:

 

Study after study shows that the earlier a child begins learning, the better he or she does down the road.  But here’s the thing:  We are not doing enough to give all of our kids that chance. The kids we saw today that I had a chance to spend time with in Mary's classroom, they're some of the lucky ones -- because fewer than 3 in 10 four-year-olds are enrolled in a high-quality preschool program. 

 Most middle-class parents can’t afford a few hundred bucks a week for private preschool. And for the poor children who need it the most, the lack of access to a great preschool education can have an impact on their entire lives. And we all pay a price for that. And as I said, this is not speculation. Study after study shows the achievement gap starts off very young. Kids who, when they go into kindergarten, their first day, if they already have a lot fewer vocabulary words, they don’t know their numbers and their shapes and have the capacity for focus, they're going to be behind that first day. And it's very hard for them to catch up over time.   

The  Federal Government now wants to extend public education down to the infant, it reminds me of the old Soviet Union and child indoctrination. Parents cannot be trusted, they may create an independent thought. Public School teachers will tow the Party line. When does the Great Leap Forward occur, when do we send the Harvard Faculty to the fields, working rice along side the new immigrants, keeping the cotton mouth snake at a distance?

Parental responsibility should not be shoved off on all the taxpayers. Especially from someone who apparently does not afford themselves of the public school system.

Are The Shipyard Workers Being Paid?

There is a piece about the current President at Newport News shipyard bemoaning the cut in the allowed expenditures. The Hill has a description. But a question when I saw the crowd. It appeared that hundreds if not thousands stopped work on "vital" ship work to stand idle as stage props. Were they still on the clock, and if so how much money was wasted there? If we had say 1,000 for 4 hours at a fully loaded salary of say $100 per hour, then that is $400,000 just standing around! What if there were more?

You see, this just makes no sense. It is not a real cut, it is a cut from an increase. The increase was more than the cut! Why all the fighting, why not negotiate. One would like to see Grammar School Report Cards, "Works Well With Others". D!

Trust, Staelin and Macroeconomics

Dave Staelin was a prominent Professor at MIT who I had the good fortune to know since my first days as a Grad student in the early 60s. In fact I believe I was in his first class as a Faculty member, Radio Astronomy if I recall. Towards the end of his life, unbeknownst to me at the time, we had many long conversations regarding the economy, economics, and what the problems were. Dave was a great thinker, a big thinker, and at the time I was just coming up the ramp of understanding what was afoot. It was 2009 and 2010, just before he passed away, we would have lunch and trade papers.

In one of his papers he wrote:

To summarize, today’s dilemma arose from the dramatic successes of modern technology in spreading knowledge and capital across the globe.  Rich nations built plants and exported both knowledge and aspirations around the globe, generously enabling poor nations that organized properly to bootstrap themselves into the restricted capital-rich sector of the global economy.  These same rich nations failed to recognize that such open exports of capital would weaken their own ability to produce and retain liquidity.  As such rich nations became dependent on others to provide goods, they first paid with other valued goods and then increasingly with credit based on trust—credit and trust that became overextended.  But loss of trust is a two-edged sword affecting both creditor and debtor, for the creditor also needs liquidity, and liquidity losses due to reductions in local or national exports propagate across the entire global trust and credit network.  Such losses force both creditors and debtors to reorganize, and if they must reorganize rapidly the resulting human displacements can further erode trust in government and self, which are the fountainheads of trust.

        Trust is key to both economic and social liquidity, for trust alone binds us locally and nationally in both our economic and social structures.  Absent trust, both are in jeopardy.

At the time I did not fully understand what was being said. Now I believe I do have a better grasp and feel it is worth sharing. You see, for Dave, Trust was what was Quality to Pirsig. Trust was the underlying element of a stable economy. Trust was what created the AD and AS that we see the macroeconomists talking about, the basis of arguments between nations. Trust is engendered by a good leader. Mis-Trust is a bad leader. A growing economy is based on Trusting the leader, or leaders, a collapsing economy is based upon mistrust.

Dave had hist upon a true piece of insight. He was fundamentally and engineer, an engineer in the true sense of the word. He believed in facts, in modelling and demonstrating the results, which is why perhaps my missing what he was saying on Trust was so easy to do, I was looking for the quantitative answer, instead he laid out an existential answer. Now as I have read and watched some of these macroeconomists I have a deepened grasp of what Dave meant. Too bad we could not continue the conversations.

What is Macroeconomics?

What is macroeconomics? All too often I read detailed analyses, in texts, the literature etc, which are the basis for the policies postulated. All too often these policies just do not work. Again and again I come back to Romer and her fallacy regarding employment and the Stimulus. Perhaps I have been the only one holding her feet to the fire.

I just spent a few days helping my grandson in Prep school understand physics, 5th former, but the fact is that I could explain by demonstrating. I can demonstrate a pulley, I buy a few at Staples, then connect them and then measure. Predictions equal experiment. It happens each and every time. Not so with anything in macroeconomics.

I wrote recently regarding the observation that the economy is all too often driven by people's opinions and beliefs. The question may be whose beliefs and opinions but that is irrelevant just now.

I saw a piece today in The Money Illusion which reinforces my point:

Most of us macro teachers work with some sort of new Keynesian model.  This is roughly the AS/AD model, with an upward sloping SRAS curve.We teach the model by repeatedly lying to our students. 

Yes indeed, they are lying, lying but having convinced themselves that somehow the math makes it all true. AD is really a belief system, consumers are happy, they believe, we have a Reagan recovery. They do not believe, Johnson and Carter, and we have inflation and recession. Do fundamentals matter? Somewhat, but I am afraid not much. Trust is key. Trust was something that an old friend Dave Staelin had been trying to get me to believe in before he passed. I was not getting it at the time, now I do, thanks Dave.

The article continues:

If oil shocks are going to raise inflation, they should lower RGDP.  Yet even during the worst of the oil shock period (mid-1973 to mid-1981) RGDP rose by 2.6% per annum.  So the inflation was almost all monetary, even if you generously assume RGDP growth would have been 3.6% in the absence of the oil shocks.  In fact, growth slowed sharply after 1973 for reasons mostly unrelated to oil; the rapid improvement in products like jet airliners and home appliances came to a screeching halt.  We shifted toward a slower growing service economy.  We couldn’t even average 3.6% growth in the 1990s, when oil got cheap and the computer revolution took off. Are these lies justified?  It’s nice to give students some real world examples of fiscal shocks and supply shocks.  But what if the message they take from this exercise is that monetary explanations of inflation and NGDP determination are “just a theory,” just as evolution or global warming are “just a theory.”  What if the public doesn’t realize that the Fed drives the nominal economy?  Might that lead to less effective public policies?  Might that have contributed in some small way to the fiasco of 2008? I think our students can handle the truth.  Why don’t we stop lying?”

Now again Trust in the leaders are essential. I think Reagan understood that, not clear of Clinton, perhaps he was just preoccupied elsewhere.

Now my favorite economist, Nick Rowe, has a posting today regarding teaching of monetary policy in macro. He states:

I always suffer self-doubt when I teach the Money part of Intro Economics. Perhaps I'm over-thinking it, and it would be better for my students if I told myself to shut up, and just give them some simple clear story. But how to get it simple and clear, yet not horribly wrong or incomplete?

 Sense a theme here folks? The Gnome from the South who blasts his instant thoughts to us from the Times would never make a statement like these two. The Blob from the West would never have such humility. But here we have two clear statements.

As Nick states when speaking of the meaning of money:

Words don't really mean anything either. But people use "cat" to mean cat, because everybody else does too. Sometimes which equilibrium we are in depends on history.

A bit of Ockham and nominalism,  but money is just easy to hold, unless and until there is a replacement, and we have been using it for a few decades now, agreed upon credit.

As Nick finishes his piece:

Because once you start talking about "the demand for money", in the same way you talk about "the demand for apples", you end up with (orthodox) nonsense like the idea that the stock of money is determined by the quantity demanded at the rate of interest set by the central bank. Which makes sense for a good like apples, which is  traded in only one market, and which people either buy or sell. But doesn't make sense for a good like money, which is a medium of exchange traded in n-1 markets, that everyone both buys and sells. The quantity of money will be determined by the demand for loans at that rate of interest, but the demand for money is not the same as the demand for loans. But that's a topic for another post. This is far too complex and too abstract. How is a first year student supposed to understand all that?

 Yes it is far too abstract. I have been tracking the FED Balance Sheet for four years plus now, watching it explode, as a result of the debt. It should make me terrified of inflation since most of that stuff has a duration and when it expires one hope they roll it over as they seem to be doing. But what if they don't, what if people believe they will not, what if people lose Trust in their Government? You see Trust really counts, it is the AD, it is the ability to "believe" in money, and it is not really measurable, you cannot come up with a stochastic differential equation defining Trust. Even at MIT, I have seen it tried.

Have They No Shame?

The upcoming "cuts" in Government spending are not only necessary but are an exercise in ferreting out those whose hold of any semblance of reality is questionable.

Take the Secretary of Transportation ans the comments in today's NY Times:

The U.S. air travel system faces widespread disruptions if automatic government spending cuts go into effect next week, Transportation Secretary Ray LaHood said on Friday, as the administration kept up a steady drum beat of pressure on congressional lawmakers to delay the cuts. 

 Now I know the Department of Transportation quite well. They are the same group who could never upgrade the air traffic control system. It is still working in a manner designed in the early 1930s! They could cut well more than any amount required by just firing every SES and GS 15 in the place! And we would actually see things get better. Imagine if they got the GS 14s and 13s as well. Why the transportation system could just go rolling on.

No, the person in charge is more interested in scaring the folks, playing the political game, and not taking one step to improve anything. Watch closely folks, what the do is what will impact the taxpayers the most while protecting the internal folks the least. So why do we have these folks in the first place? Does anyone remember?

Thus would anyone believe this person when the Times continues:
 

However, LaHood and other administration officials have repeatedly denied that they have any discretion in applying the cuts or that they are exaggerating their impact. 

"The idea that we're just doing this to create some kind of a horrific scare tactic is nonsense," LaHood said. "We are required to cut a billion dollars. And if more than half of our employees are at the FAA ... there has to be some impact." 

I would doubt so!

As an afternote I did the calculation of what we would save by just dropping all GS14-14s from the payroll. Salary alone is $26 Billion, the details are:

Salary	Number	Total ($000,000)
$136,771	121,531	$16,621.92
$155,500	61,404	$9,548.32
		$26,170.24

Now if we recognize benefits etc we would save at least another 50% or a total of about $40 Billion. Well there goes the Sequester.

More Details on ACA

The HHS issued some more of the rulings on the ACA implementation today:

Today’s final rule implements five key provisions of the Affordable Care Act that are applicable to non-grandfathered health plans:

• Guaranteed Availability
  Nearly all health insurance companies offering coverage to individuals and employers will be required to sell health insurance policies to all consumers. No one can be denied health insurance because they have or had an illness.
• Fair Health Insurance Premiums
  Health insurance companies offering coverage to individuals and small employers will only be allowed to vary premiums based on age, tobacco use, family size, and geography.  Basing premiums on other factors will be illegal.  The factors that are no longer permitted in 2014 include health status, past insurance claims, gender, occupation, how long an individual has held a policy, or size of the small employer.
• Guaranteed Renewability
  Health insurance companies will no longer refuse to renew coverage because an individual or an employee has become sick.  You may renew your coverage at your option.
• Single Risk Pool
  Health insurance companies will no longer be able to charge higher premiums to higher cost enrollees by moving them into separate risk pools.  Insurers are required to maintain a single state-wide risk pool for the individual market and single state-wide risk pool for the small group market.
• Catastrophic Plans
  Young adults and people for whom coverage would otherwise be unaffordable will have access to a catastrophic plan in the individual market.  Catastrophic plans generally will have lower premiums, protect against high out-of-pocket costs, and cover recommended preventive services without cost sharing.

 We have estimated that the costs of these plans will be significantly higher. Why not vary costs on such things as weight, a major health cost, and drug usage, also significant, STD status, and other sets of well accepted metrics?

HHS Issues Rules

The HHS has issued ( see Federal Register )another set of rules regarding the implementation of the ACA. These are:

Essential Health Benefits

The Affordable Care Act ensures Americans have access to quality, affordable health insurance. To achieve this goal, the law ensures that health plans offered in the individual and small group markets, both inside and outside of Health Insurance Marketplaces, offer a core package of items and services, known as “essential health benefits.” Under the statute, EHB must include items and services within at least the following 10 categories:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

The Affordable Care Act also directs that EHB be equal in scope to benefits offered by a “typical employer plan.” To meet this requirement in every state, the final rule defines EHB based on a state-specific benchmark plan. States can select a benchmark plan from among several options, including the largest small group private health insurance plan by enrollment in the state. The final rule provides that all plans subject to EHB offer benefits substantially equal to the benefits offered by the benchmark plan. This approach best strikes the balance between comprehensiveness, affordability, and state flexibility. The final rule also gives issuers the flexibility to offer innovative benefit designs and a choice of health plans.

These are still defined as a process not as a fait accompli.  The costs of these mandated coverages we suspect will be significant. One must remember that they apply to all coverage and thus include an expansion of Medicare not only to those covered but to the added 40 million to e covered.

Patents, Innovation and 3D Printing

I spent some time at Edison's Lab a couple of days ago and saw the massive number of things he had patented, for better or worse. He personally amassed some 1,000+ patents, a feat allowed by having lots of lawyers.

 I was then interested to see a piece in Wired on the 3D printers bemoaning the number of blocking patents in existence which will make consumer based 3D printing a thing of the distant future. That frankly is a shame. You see Edison had lots of machinists who could make from metal anything he dreamed up. At the time they machinists were cheap and the technology was expensive. But he could crank out anything. 3D printing could do for our economy what the PC did in the early 80s. But due to the Patent office it will not. Apparently the Patent office will patent anything, thus creating massive road blocks filled with litigation. We have created the seeds of our own destruction.

To quote Wired:

If you're waiting for desktop additive-manufacturing technology to move closer to professional-level results, be prepared to wait for a very long time....We've uncovered 10 patents that could severely stifle innovation in the low-cost segment of the 3-D printing market and keep you from making colorful, smooth-finished figures and precise, articulating parts. These patents cover core technologies and ease-of-use features, and could take momentum from the upstarts and return it to the entrenched companies.

 Indeed, the patents will block any such innovation. The tool would have allowed for the explosion in 3D product and technology creativity. The 3D printer is what programs were in the 80s, we had millions of new applications, and the 3D printer would facilitate millions of new "things", things which could create considerable prosperity. Yet if not here in the US, it will more than likely leak to other less controlling countries.

I am not a fan of patents. I understand them and have been through the process. Some are beneficial but all too often they become trolls under the bridge, bringing no true value, just fees.

Does This Make Any Sense?

I am often amazed by the nastiness and smugness of the left. Perhaps it is just me, but MSNBC folks have the smirk on their faces that is pandemic amongst the left, that look like we are right and you are just dumb, real dumb.

Now there is a chubby economist on the left coast who for reasons known only to him, has this habit of making snarky comments about those he opposes. I can see this on some electronic instant messaging but from an accredited full professor type, it is unbecoming. It is akin to the gnome from the South upon whom I had  placed some remarks recently.

The issue is Say's Law. Say I gather was some economist, or so they so tell, and his "Law" is either believe or doubted. Frankly it is irrelevant. The fact is that people respond to what they believe, and belief is a stronger driver than all these facts. That is to some degree the essence of Nick Rowe's soul searching and it is at the core of what I termed the Rowe Conjecture. It is a battle between belief and fact. Belief drives so many things, despite the facts. The collapse of the housing market was as much driven by the belief that made it grow and then tore it down.

Now economists have no real way to measure belief. And, yes, people believe different things, so there is no one belief. Just go to the racetrack. That is the heaven of belief.

Thus if someone makes a statement which flies in the face of the "Law" of whatever economist stated it, one should always remember that belief tops any law. And, yes, we have not yet figured out how to measure that o less change it. Although true leadership can often do so. Sadly we have none.

USPTF, CCE, Melanoma, and Survival

Screening for melanoma should be a simple task, especially with the recent use of dermoscopy, but somehow it is not. The USPTF is one of the many bodies under the ACA which will create limitations on patient care, namely a means to reduce costs. Melanoma is an all too tragic disease, one which should and can be militated against. Unfortunately the death rate from melanoma has not decreased and with the current recommendations it may very well increase.

Let us begin by reviewing the current Government ruling on skin examination. One should remember that this is the basis for Comparative Clinical Effectiveness, CCE. We discussed this issue just a few postings back. We have also been concerned since the beginning of the ACA debacle about its negative impact on Health Care. The USPTF has presented a set of at best non-recommendations[1].

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for skin cancer by primary care clinicians or by patient skin self-examination. (I statement)

Namely the recommendation is that primary care physicians are not trained to make a correct diagnosis. However it does not admit that Dermatologists do so as well. One may envision a great opportunity for Teledermoscopy allowing the capture of in office dermoscope images and then referral to a Dermatologist. Reading the dermoscopic images takes less than a minute by a trained Dermatologist and the specificity of such a reading can be quite high.

The USPTF Report continues:

Primary care physicians are moderately accurate in diagnosing melanoma, with a sensitivity of 42% to 100% and a specificity of 70% to 98%. A large systematic review analyzed the evidence on diagnostic accuracy of primary care physicians and dermatologists; most of the studies used images of lesions that had been histologically confirmed. The systematic review included 11 studies with primary care physicians and found a sensitivity of 42% to 100% and a specificity of 98% in the diagnosis of melanoma. The authors concluded that the evidence was insufficient to determine whether dermatologists and primary care physicians differed in accuracy . However, most studies on the accuracy of diagnosis of melanoma by primary care physicians evaluated the ability to identify melanoma from images of lesions of a known diagnosis; the applicability of this evidence to a whole-body skin examination in the setting of screening for skin cancer is not clear.

In a recent Editorial in Investigative Dermatology the authors state regarding recent and currently standing USPTF recommendations the following[2]:

….. incorporating new policy initiatives is paramount. The USPSTF recently gave a B-level recommendation for behavioral counseling to prevent skin cancer in patients 10 to 24 years old, an upgrade from the previous I rating (insufficient evidence). Such ratings indicate at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms. Results from the well-executed German screening and educational program (albeit not a randomized study) should now be proactively shared with the USPSTF, which has previously argued that there is insufficient evidence to support the recommendation of population- based skin cancer screening. In its most recent report on screening, the USPSTF noted that “no studies of the benefits of screening have compared a screened population with an unscreened population with respect to appropriate health outcomes”

This is recommendation is vague and to some degree flies in the face of the obvious. Screening, especially with a dermoscope, works in most cases. The specificity is high, and even if in doubt the removal of a questionable lesion is hardly traumatic.

A study of potential harms of screening is key—although the USPSTF has expressed concern that false-positive results may lead to biopsies and unnecessary treatment, they have acknowledged that the evidence to back up this theory is limited. Screening should be lodged within closed health-care systems that have experience in large screening trials and the demonstrated ability to follow up on all participants.

They would also need to be capable of capturing melanoma thickness, mortality, and other relevant data. In addition, there may be the potential to seek funding for a Medicare demonstration project, possibly in a state with high melanoma mortality rates and physician networks lodged in underserved areas. Lessons can be learned on obtaining cost estimates for broad-scale public health efforts from the Assessing Cost-Effectiveness– Obesity group and its important contribution to obesity prevention programs.

The authors of the Editorial conclude:

In summary, in the United States, melanoma remains the only preventable cancer for which mortality rates are not dropping. Nevertheless, population- wide screening rates remain low. As melanoma rates continue to rise and patient demand for screening accelerates, the current deficit in the dermatology workforce will become even more apparent. However, a confluence of new developments holds much promise. Web-based technology affords the potential to teach standardized skin cancer examinations to physicians, physician extenders, and high risk patients in multiple settings. Digital dermoscopy offers clinicians new options for distinguishing between benign, atypical, and aggressive lesions.

The Affordable Care Act has the promise of providing screenings to the majority of the US high-risk population that has yet to be screened. Finally, the results of the German screening program provide new and important evidence for the value and benefits of visual examination for melanoma.

Thus we believe that although such screening is possible, and highly productive in reducing morbidity and mortality, the way the USPTF phrases its results will have a negative impact on patient survival.

References

USPTF, Screening for Skin Cancer: U.S. Preventive Services Task Force Recommendation Statement, Ann Intern Med. 3 February 2009; 150(3):188-193

Geller, A., A. Halpern, The Ever-Evolving Landscape for Detection of Early Melanoma: Challenges and Promises, Journal of Investigative Dermatology (2013) 133, 583–585.

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[1] http://annals.org/article.aspx?articleid=744253

[2] http://www.nature.com/jid/journal/v133/n3/pdf/jid2012360a.pdf?WT.ec_id=JID-201303

Passing On the Misinformation

I gather that there is some inside the Beltway rumor mill which maintains urban legends for long periods of time. Furthermore they are reproduced without anyone ever asking if they are true, or what the basis is of the legend.

Klein in the Washington Post reiterates the fallacy when he states:

7. “Two married recent retirees who had typical earnings over their lives will have paid about $88,000 in dedicated Medicare taxes through the payroll tax, according to a calculation by Eugene Steuerle, Stephanie Rennane and Caleb Quakenbush, all of the Urban Institute. That sum includes the portion of the tax that employers pay and is expressed in today’s dollars (adjusted for both inflation and the interest the money would have earned over the years). In return for the $88,000 in lifetime taxes, that married couple can expect to receive benefits worth more than three times as much: $387,000.”

8. “Patients and doctors alike gravitate toward the latest, most expensive treatment, regardless of whether it is the most effective. Common treatments for prostate cancer, for example, range from about $25,000 to more than $100,000. “No therapy has been shown superior to another,” an analysis by the RAND Corporation concluded. But which therapies are growing the most rapidly? The most expensive ones, like proton radiation therapy. ”

Klein has allegedly obtained these from some book by Leonhardt at the NY Times. Now let me comment on both, and my comments are based upon verifiable facts, generally primary research.

First, the hypothetical couple mentioned in the first paragraph are in the bottom 20% of the income base. For the upper 80% of the folks, why they contribute a great deal more, and in fact the top 40% contribute well in excess of what they get in return. In fact, the lower the income the sicker the person, thus the lower incomes use most of the services and pay least of the funds. I did an extensive analysis of this about 4 years ago, updated it 2 years ago. Thus it would help to understand the facts and not merelt parrot what they find to validate their opinions. But alas it is the Press, and we really have such a poor Press.

Now for the second. Here I wrote a detail draft book on Prostate Cancer. The statement that no therapy has been shown to be superior is not quite correct. It all depends and the details must be examined. In fact there is a gross distortion of the underlying evidence to condense the result in such a statement. For aggressive yet localized PCa, surgery can be quite effective. For indolent PCa, one might just leave it alone. The problem is we have not yet determined the nest way to split the two. That is the real answer, not what is quoted above.

The Press all too often never does due diligence on what they believe are facts. They are all too often just urban legends.

The (New) New Republic, Croly may be turning in his grave, has written a piece which is rather down on the young man making the statements from his beloved economic writer. Notwithstanding the long piece, and the critique from the left leaning economists, failing to validate facts is a valid criticism.